6.ENDODONTIC DIAGNOSIS AND RECENT MODALITIES.pptx

 The art of identifying a disease from its signs and
symptoms.
 The purpose of the diagnosis is to determine what
problem the patient is having and why the patient
is having that problem.

 The process of making a diagnosis can be divided into
five stages:
 The patient tells the clinician why the patient is
seeking advice.
 The clinician questions the patient about the
symptoms and history that led to the visit.
 The clinician performs objective clinical tests.
 The clinician correlates the objective findings
with the subjective details and creates a
tentative differential diagnosis.
 The clinician formulates a definitive diagnosis.

Chief complaint
Medical
history
Dental
history
Clinical
inspection
Diagnostic
tests
Radiographic
Interpretation
Data Evaluation
Diagnosis

 Generally patients seeks the dentist for his chief complaint.
 It may relate to pain, swelling, lack of function or esthetics,
which the patient has brought him to the dentist.
Pain :
 Common complaint which leads to the dental treatment
 One should ask the patient about the kind of pain, its
location, its duration, what causes it, what alleviates it

Brannstrom’s hydrodynamic theory:
Proposed that pulp pain is a result of nociceptors
activated by fluid movement with possible
other irritants through the patent dentine tubules
PULPITIS resulting from rapidly progressing caries as an
example, seems to be more likelihood of having pain because
there is less time for the dental pulp to react and protect
itself by occluding the dentinal tubules

 Sharp, piercing and
lancenating.
 Faster rate of transmission
 Responds to pain,
temperature, touch
 Diameter is 1-5 µm
 Conduction velocity 6-30
m/sec.
 Has mylein sheath
 Located in the periphery of
pulp, penetrating the inner
part of dentin.
 Dull, boring, gnawing and
excruciating.
 Slower rate of transmission
 Responds to pain
 Diameter 0.4-1.o µm
 Conduction velocity 0.5-2
m/sec
 Does not so
 Located in deeper part of
pulp proper.
A delta fibers C fibers

 Extra oral sewlling of odontogenic origin
typically is the result of endodontic etiology.
Abscess Cellulitis

Canine Space
Infection
- Obliteration of
naso-labial fold
- Swelling may
extend involving
the lower eye lid
Buccal Space
Infection
- Seen usually in
the posterior
cheek
- Diffuse
swelling
Sub Mandibular
Space infection
- Seen usually in
the floor of the
mouth

Soft Tissue Examination
 There should be a routine examination of the intra oral soft tissues.
 The gingiva and mucosa should be made dry or wipe with gauze.
Any raised lesions or ulcerations should
be documented and when necessary,
evaluated with biopsy or referral

 Color : Normal teeth show life like translucency and sparkle that
is missing in pulpless teeth which appear more or less opaque.
 Contour : examination of contours of affected teeth, such as
fractured teeth, wear facets, improperly contoured restorations or
altered crown contours - as these factors can have marked effect
on the respective pulps.
 Consistency : change in consistency is related to presence of
caries, external and internal resorption.

 Tooth is struck with a quick,
moderate blow initially with low
intensity by the finger, then with
increasing intensity by using handle
of an instruments.
 A positive response to percussion
indicates not only the presence of
inflammation of periodontal ligament
but also the degree of inflammation.

 Simple test done with finger tip using light
pressure to examine tissue consistency and
pain response.
 Presence, intensity and location of pain.
 Presence and location of adenopathy
 Presence of bone crepitus.
 Whether tissue is fluctuant and enlarged
 When infection confined to pulp palpation
is not diagnostic.

 Rationale of mobility test is to evaluate the
integrity of the attachment apparatus surrounding
the tooth.
 Test consists of moving the involved tooth facio-
lingually using handles of two instruments or using
two index fingers.
 Test for depressibility is performed by applying
pressure in an apical direction on the
occlusal/incisal aspect of tooth and observing
vertical movement if any.

 Consists use of a blunt calibrated probe
to explore the integrity of gingival
sulcus around each tooth.
 To distinguish disease of periodontal
origin from pulp origin, thermal and
EPT along with PDL probing are
essential.

Class I: The furcation can be
probed but not to a
significant depth
Class II: The furcation can be
entered into but cannot be
probed completely through
to opposite side.
Class III: The furcation can
be probed completely
through the opposite side.

Pulp Sensibility tests Pulp Vitality tests
Assessment of the Pulp’s
Sensory Response:
Sensibility is defined as
the ability to respond to a
stimulus
 Assessment of the Pulp’s
Blood Supply :
Pulp tissue may have an
adequate vascular supply, but
is not necessarily innervated.
Thermal test
Heat test
cold test
Electric Pulp Tester
 Laser Doppler
Flowmetry
Pulse Oximetry
Surface temperature
measurement

Radiographs
Test cavity
Anaesthetic test
Transillumination
Bite test

Heat test
Gutta percha stick
Hot burnisher
Hot water
Hot air
Hot compound
Polishing cups

Cold test
Cold air
Ice sticks and CO2
snow(-78 ºc)
Dichloro-difluoro-
methane(-26ºc)
Ethyl chloride spray
(-50ºc)

 No response
 Mild to moderate degree of pain that
subsides within 1-2 sec after stimulus
has been removed
 Strong, momentary painful response
that subsides within 1-2 secs after
stimulus is removed
 Moderate to strong painful response
that lingers for several seconds or
longer after stimulus has been
removed
Non-vital pulp is indicated.
Normal
Reversible pulpitis
Irreversible pulpitis

•Retract the patient’s cheek with free hand, this
completes the circuit
•Turn on the rheostat slowly introduce minimal
current into the tooth and increase the current
slowly.
•Ask the patient to indicate tingling or warmth
sensation, and note the recordings.
•Repeat the foregoing for each tooth to be
tested.
•Describe the test in a simple way so that it
reduces the patient anxiety.
•Isolate the area of the teeth by suction and
cotton rolls.
•Check the EPT.
•Apply electrolyte on the tooth electrode and
the dried enamel (should not contact the
restoration or gingival tissue ).
 EPT is designed to stimulate a response of sensory fibres within
the pulp by electric excitation.
Procedure

 Disadvantage :
Cannot be used on patients having cardiac pace maker.
Does not suggest the health or integrity of the pulp, simply
indicates the presence of vital sensory fibres with in the pulp.
Does not provide any information about vascular supply of
pulp, which is the true determinant of pulp vitality.

 Recently traumatized
teeth
 Incomplete root formation
 Sedative medication taken
by the patient
 Unusual pain thresold by
the patient.
 Teeth with extensive
restoration
False Positive False Negative
Response means pulp is
necrotic, patient feels
sensation in tooth.
Response means that pulp is
vital, but patient does not
respond.
 Gangrenous pulp in root
canal
 Multi-rooted teeth
 Electrode may contact the
metal restoration

Bisecting Angle Technique Paralleling technique
Image distortion seen
Distortion is greater in
apical zone
Anatomical land marks
altered
Crown-root ratio not
preserved
Poor image
standardization and
reproducibility
Slight image distortion
Distortion equal
throughout the image
Correct anatomical
relationships
Crown-root ratio
preserved
High image
standardization and
reproducibility

Presence of caries that may
involve or threat to involve the
pulp.
May show the number, curve,
length and width of root canals.
Presence of calcified materials in
the pulp chamber or root canals.
Resorption of dentin
originating with in the root
canal or from the root surface.
Thickening of PDL
Nature and extent of
periapical and alveolar bone
destruction.

 Developed in France by Dr. Francis Mouyen in 1984.
 The system provides an instantaneous image on a video monitor
while reducing radiation exposure by 80%.
 Three components:
 Radio component
 Visio component
 Graphy component

1. Radio component:
 It consists of a hypersensitive intra-oral sensor and a
conventional X-ray unit.
 The small sensor consist a fluoroscopic sensor screen, a set of
optic fibres, and a miniature charged coupling device; that
translates the image produced into an electronic signal that is
transmitted to display – processing unit.
2. Visio component:
 It consists of a video monitor and display – processing unit.
 As the image passes to the processing unit, it is digitized,
memorized by the computer and immediately displayed on the
monitor.
 This image is magnified four times.

3. Graphy component:
 A high resolution printer that instantly provides a hard copy of the
screen image, using the same signal.
 Advantages:
◦ Eliminates the use of X-ray film.
◦ Significant reduction in exposure time (100th of sec).
◦ Instantaneous image display.
◦ It can display multiple images.
◦ As the image is digitalized further manipulation of image is possible.

 Helps in the detection of radiographic changes by decreasing
the amount of distracting background information .
 By allowing the eye to focus on the actual change that has
occurred between the two images

 A radiographic image is generated before a particular
treatment is performed.
 At some time after the treatment, another image is generated.
 The two images are digitized and compared on a pixel-by-
pixel basis.
 The resultant image shows only the changes that have
occurred and “subtracts” those components of the image that
are unchanged.
Mechanism:
•In diagnosis of periodontal progression
•In diagnosis of healing after root canal therapy
•In diagnosis of the progression of periradicular
lesions.

 Invented by Chester.F Carlson in 1937.
This technique uses a rigid aluminium photo
receptor plate coated with a layer of vitreous
selenium
The selenium particles are given a uniform
electrostatic charge. The charged plate is placed
into a air tight, light tight cassette.
These selenium plates when it gets exposed, it
results in selective discharge – forms latent image
The latent image is then converted into a visible
image in a unit called processor
Once the latent image is converted into a real image
on paper the selenium plate can be discharged,
cleaned and used again.

 If source of pain is not determined whether
in maxillary or mandibular give inferior
alveolar block.
 Using either infiltration or the
intraligamentry injection inject the most
posterior tooth in the area suspected of
being the cause of pain.
 If pain persists, anesthesize the next tooth
mesial to it and continue to do so until the
pain disappears.

 Direct dentin stimulation.
 The test cavity involves slow removal of
tooth structure to determine pulp vitality.
 The cavity is prepared with a round bur at
slow speed without a coolant-
unanesthetized tooth.
 This test is carried out only when other
means have failed therefore disadvantage
of this test is iatrogenic damage.
 Pain or sensation felt by patient indicates
vital pulp and test is performed on other
teeth until the involved tooth is found.

 The test requires shining a light from lingual /
palatal surface.
 Transmission of powerful fiber optic light
through teeth helps to detect a fracture mainly
the vertical.
 During this test, operating light is switched
off and fiberoptic light is moved closed to neck
of the tooth.
 Light does not pass through fracture, thus the
part of tooth beyond fracture remains dark.
 In teeth with necrotic pulps the shadow of the
pulp canal space appears darker than the rest
of the tooth because of the break down of the
blood cells.
 In vital pulps no differentiation is noted.

 The tooth may be sensitive to biting when the pulpal
pathosis has extended into the periodontal ligament
space, creating a peri-radicular periodontitis or
secondary to a crack in the tooth.
 If peri-radicular periodontitis is present the tooth
will respond with pain to percussion and biting
test,regardless where the pressure is applied to the
coronal part of the tooth.
 A cracked tooth and fractured cusp will elicit pain
only when the percussion or bite test is applied on a
certain direction to one cusp or section of the teeth.

Crown surface temperature/heat
registration
Laser Doppler flowmetry
Pulse oximetry
Computerised tomography
Plethysmography
CBCT
MRI- Magnetic resonance imaging
Ultrasound
Transmitted Laser Light

The tooth suspected of being pulpless
and its contra-lateral tooth were cooled
By covering both teeth with a piece of
gauze that had been saturated with cold
tap water 10 degree celsius.
After cooling for 1 min , the teeth were
isolated with cotton rolls and air dried
Tooth temperature was monitered with
the thermositor and after a period of 3-5
min
Show that when teeth have been cooled, non-
vital teeth were slower to rewarm than vital
teeth

 LDF is another non-invasive
method for assessing blood flow in
microvascular systems.
 It use in teeth was first described
by Gazelius and co-workers in
1986.
 Since then, the technique has been
widely used to monitor dynamic
changes in pulpal blood flow in
response to pressure changes and
following administration of local
anaesthesia

The technique utilizes a beam of infrared
light produced by a laser that is directed into
the tissue.
As light enters the tissue, it is scattered and
adsorbed by moving red blood cells and
stationary tissue elements.
Photons that interact with stationary
elements are scattered but are not Doppler
shifted.
Photons that interact with moving red blood
cells are scattered and frequently shifted
according to the Doppler principle
A portion of the light is returned to the
photon detector, and a signal is produced.
 Motion artefact due to uncontrolled movement of the probe
when placed against the tooth.
 Blood pigments within a discolored tooth crown can also
interfere with laser light transmission

 It was invented by Aoyagi in the early 1970, for recording
blood oxygen saturation levels during the administration of
intravenous anaesthesia.
The pulse oximeter sensor consists of
two light-emitting diodes, one to
transmit red light (640 nm) and the
other to transmit infrared light (940
nm), and a photodetector on the
opposite side of the vascular bed.
Oxygenated haemoglobin and
deoxygenated haemoglobin absorb
different amounts of red/infrared
light.
The pulsatile change in the blood
volume causes periodic changes in
the amount of red/ infrared light
absorbed by the vascular bed before
reaching the photodetector.
The relationship between the
pulsatile change in the absorption
of red light and the pulsatile change
in the absorption of infrared light is
analysed by the pulse oximeter to
determine the saturation of arterial
blood.

0
50
100
150
Cold test EPT Pulse
oximetry
% Success
88
90
92
94
96
Cold test EPT Pulse
oximetry
%Success
Normal Teeth Necrotic teeth

 It is a method for assessing the changes in volume and has
been applied to the investigation of arterial disease.
 It can be performed using air filled cuffs or mercury in rubber
strain gauges.
 As the pressure pulse passes through the limb segment, a wave
form is recorded which relates closely to that obtained by
intra-arterial cannulation
 The same principle is used to assess tooth vitality.
 Presence or absence of a wave form can indicate the status of
the tooth

 The medical CT scanner was developed in the late 1960s, and
subsequently patented by Hounsfield (1973)
 Trope et al in 1989.
 The lesions were differentiated on the basis of radiographic
densities between the content of the cyst cavity and
granulomatous tissue.
 The CT scan measures the x-ray attenuation in terms of HU.
 Hounsfield is used to describe the amount of x-ray attenuation
of each voxel (volume element) in 3-dimensional image obtained
by CT scan.

 The voxels are normally represented
as 12-bit binary numbers, and
therefore have 4096 possible values.
 These values are arranged on a scale
from -1024 HU to +3071 HU,
calibrated so that -1024 HU is the
attenuation produced by air and 0
HU is the attenuation produced by
water.
 Tissue fluids and soft and hard
tissues produce attenuations in the
positive range.

 In the late 1990s Italian and Japanese groups (Arai et al. 1999,
Mozzo et al. 1998),
 The X-ray beam is cone-shaped (hence the name of the technique),
and captures a cylindrical or spherical volume of data, described as
the field of view.
 CBCT has a rapid scan time of 10-70 secs.
 The spatial resolution of CBCT images (0.4mm to 0.076mm or
equivalent to 1.25 to 6.5 line pairs/mm¯¹.

Internal resorption of the maxillary Right incisor and
External cervical resorption of the maxillary left Incisor
teeth

 MRI uses nonionizing radiation from the radiofrequency (RF)
band of the electromagnetic spectrum.
 To produce an MR image, the patient is placed inside a large
magnet, which induces a relatively strong external magnetic
field.
 This causes the nuclei of many atoms in the body, including
hydrogen, to align themselves with the magnetic field.

 After application of an RF signal, energy is released from the
body, detected, and used to construct the MR image by
computer.
 The high contrast sensitivity of MRI to tissue differences and
the absence of radiation exposure are the reasons MRI for the
most part have replaced CT for imaging soft tissue.
 CT remains an important technique for imaging bony tissues.

Applications:
◦ Imaging of the jawbones, including teeth, pulp spaces and
periapical tissues.
◦ Pulps were better visualized after administration of a
contrast medium.
◦ In detection of periapical pathosis.
◦ Edema in the periapical region is detectable.
◦ Any interruption of the cortical plates is also easily seen.
◦ Areas of bone sclerosis, which usually surround the
periapical lesion, are seen as very low signals (black).

 Real time echotomography or echography.
Producing a sound wave
A sound wave is typically produced by a piezoelectric
transducer encased in a housing which can take a number of
forms.
Strong, short electrical pulses from the ultrasound machine
make the transducer ring at the desired frequency.
The sound is focused either by the shape of the transducer, a
lens in front of the transducer, or a complex set of control
pulses from the ultrasound scanner machine.

This focusing produces an arc-shaped
sound wave from the face of the
transducer. The wave travels into the
body and comes into focus at a desired
depth.
In addition, a water-based gel is
placed between the patient's skin and
the probe.
The sound wave is partially reflected
from the layers between different
tissues.

 Receiving the echoes
The return of the sound wave to the transducer
results in the same process that it took to send the sound wave,
except in reverse. The return sound wave vibrates the
transducer, the transducer turns the vibrations into electrical
pulses that travel to the ultrasonic scanner where they are
processed and transformed into a digital image.

 Displaying the image
Images from the sonographic scanner can be displayed,
captured, and broadcast through a computer using a frame
grabber to capture and digitize the analog video signal. The
captured signal can then be post-processed on the computer
itself.

 When an area in a given tissue has high echo intensity –
HYPERECHOIC
 Low echo intensity – HYPOECHOIC
 Absence of echo intensity – ANECHOIC
Any fluid filled area where no reflection
occurs in anechoic, whereas bone, from total
deflection occurs is hyperechoic.

 The interpretation of grey values on an image is based on a
qualitative comparison of the echo intensity with that of
normal tissue.

Application:
◦ Diagnosis & follow-up of extensive periapical lesions.
◦ Information on the size of the lesion and has a low
radiation risk.
◦ It has a potential to describe the contents of the lesions (i.e.
watery versus corpuscolated)
◦ Their vascularization may become an important factor
when making a differential diagnosis between lesions of
endodontic origin (i.e. granulomas versus cysts) and also
between other lesions of the maxillary bones.
◦ Ultra-sound guided BIOPSY.

 They concluded Conventional and digital radiography enable diagnosis
of periapical diseases, but not their nature, whereas ultrasound provides
accurate information on the pathologic nature of the lesions, which is of
importance in predicting the treatment outcome.
 Therefore ultrasound can be used as an adjunct to conventional or
digital radiography in diagnosing periapical lesions.
Comparison of the efficacy of conventional radiography, digital
radiography, and ultrasound in diagnosing periapical lesions
Namita Raghav et al oooe 2010

 It uses similar sending/receiving probes as conventional LDF,
but the probes are separate.
 Thus the laser beam is passed through from the labial or buccal
side of the tooth to the receiver probe which is situated on the
palatal or lingual side of the tooth.
 The limitations -where obstruction and/or interference from
within the tooth structure will affect the results.

 The assessment of pulp is a crucial diagnostic procedure in the practice
endodontics.
 Pulp tests include sensibility and vitality tests.
 It is essential that clinicians understand the limitations of these tests
and their usefulness.
 They are important diagnostic aids; however, their results must be
interpreted in conjunction with consideration of:
◦ a detailed history,
◦ the symptoms,
◦ the clinical findings,
◦ radiographic observations &
◦ judicial use of advanced diagnostic aids.
 A diagnosis can only be reached once all the information has been
gathered and assessed

 Cohen 10th edition
 Ingle 6th edition
 Arnaldo Castelluci Vol I
 Color atlas of Endodontics by William T.Johnson
 Endodontic therapy 6th edition – Franklin S.Weine
 Nafiseh Dastmalchi, Hamid Jafarzadeh, and Saeed Moradi,
Comparison of the Efficacy of a Custom-made Pulse Oximeter Probe
with Digital Electric Pulp Tester, Cold Spray, and Rubber Cup for
Assessing Pulp Vitality .Journal of Endod ontics2012;38:1182–1186.
 Velayutham Gopikrishna, Kush Tinagupta and Deivanayagam
Kandaswamy. Comparison of Electrical, Thermal, and Pulse Oximetry
Methods for Assessing Pulp Vitality in Recently Traumatized Teeth.
Journal of Endodontics 2007;33:531–535.

 Patrick Tsai, Mahmoud Torabinejad,Dwight Rice, and Bruno Azevedo.
Accuracy of Cone-Beam Computed Tomography and Periapical
Radiography in Detecting Small Periapical Lesions. Journal of
Endodontics 2012;38:965–970.
 Namita Raghav, Sujatha S. Reddy, A. G. Giridhar, Srinivas Murthy,
Yashodha Devi B. K,,N. Santana, N. Rakesh, MDS,and Atul Kaushik .
Comparison of the efficacy of conventional radiography, digital
radiography, and ultrasound in diagnosing periapical lesions. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2010;110:379-385.
 Velayutham Gopikrishna, Gali Pradeep and Nagendrababu
Venkateshbabu Assessment of pulp vitality: a review. International
Journal of Paediatric Dentistry 2009; 19: 3–15
 Thomas R. Pitt Ford & Shanon Patel. Technical equipment for
assessment of dental pulp status. Endodontic Topics 2004, 7, 2–13.

 Eugene Chen and Paul V. Abbott. Evaluation of Accuracy, Reliability,
and Repeatability of Five Dental Pulp Tests. Journal of Endodonics
2011;37:1619–1623.
 Hamid Jafarzadeh, and Paul A. Rosenberg. Pulse Oximetry: Review of
a Potential Aid in Endodontic Diagnosis. Journal of Endodontics
2009;35:329–333.
 Eugene Chen and Paul V,Abbott Dental Pulp Testing: A Review.
International Journal of Dentistry 2009.
 E. Smith, M. Dickson, A. L. Evans,D. Smith & C. A. Murray.An
evaluation of the use of tooth temperature to assess human pulp
vitality. International Endodontic Journal, 37, 374–380, 2004.
 D. Evans, J. Reid, R. Strang, andD. Stirrups, “A comparison of
laser Doppler flowmetry with other methods of assessing the
vitality of traumatised anterior teeth,” Dental Traumatology,
vol. 15, no. 6, pp. 284–290, 1999

 Eugene Chen and Paul V. Abbott Dental Pulp Testing: A Review .
International Journal of Dentistry.
 A. H. Rowe and T. R. Pitt Ford, “The assessment of pulpal vitality,”
International Endodontic Journal, vol. 23, no. 2, pp.77–83, 1990.
 H. Jafarzadeh and P. V. Abbott , Review of pulp sensibility tests. Part
I: general information and thermal tests. International Endodontic
Journal, 43, 738–762, 2010.
 H. Jafarzadeh and P. V. Abbott Review of pulp sensibility tests. Part
II: electric pulp tests and test cavities. International Endodontic
Journal, 43, 945–958, 2010.

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